A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?
Administer a bolus of IV normal saline as ordered
Flush the peritoneal catheter with normal saline
Assess the client for signs of infection
Continue to monitor the color of the dialysate
The Correct Answer is C
Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.
Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.
Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.
Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.
Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.
Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.
Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.
Correct Answer is ["50"]
Explanation
The correct answer is 50 drops per minute
Explanation:
Step 1 is identify the total volume to be infused
50 mL
Step 2 is identify the time in minutes
1 hour = 60 minutes
Step 3 is identify the drop factor for a microdrip set
Microdrip = 60 drops per mL
Step 4 is multiply the volume by the drop factor
50 × 60 = 3000 drops
Step 5 is divide total drops by time in minutes
(3000 ÷ 60) = 50
Result = 50 drops per minute
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